Bleeding complications after use of novel oral anticoagulants in patients undergoing cardiac surgery.

Hassan K, Bayer N, Schlingloff F, et al.
Ann Thorac Surg 2018;105:702-708.
NATA Rating :
Review by : J. H. Levy
NATA Review

The authors evaluated 81 patients treated with non-vitamin K oral anticoagulants (NOACs) who underwent elective cardiac surgery at their insitution between July 2014 and June 2016. Among these patients, 37 were on rivaroxaban (45.7%), 35 on apixaban (43.2%), and 9 on dabigatran (11.1%). Cardiac surgery with cardiopulmonary bypass was performed at a median 4 days (IQR: 3 to 6) after stopping the NOAC.

The authors report that reduced renal function was predictive for ICU length of stay and red blood cell transfusions and suggest that anticoagulant withdrawal interval significantly influenced postoperative drainage volume. Of note was that 5 patients (6.2%) required reexploration because of bleeding (4 apixaban patients and 1 rivaroxaban patient). ICU stay was 2 days after a NOAC withdrawal of 10 days, compared with 4.2 days without interruption.

The authors suggest that, despite current recommendations, patients should whenever possible not be considered for elective cardiac surgery within 10 days of withdrawing NOAC treatment. I do not think their data support their conclusion. Median chest tube drainage was 480 mL. Of note was that none of the dabigatran patients bled, and there is no mention of dabigatran reversal with idarucizumab that was approved midway in their data collection. Although renal function was moderately to severely impaired in 81.5% of their patients, the direct factor Xa inhibitors studied have less renal clearance dependence than dabigatran. Overall, this report is not consistent with other reports or current recommendations.

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